Sweet Glomerulus: A Case of Diabetic Nephropathy

Chapter 7
NURSING CARE PLANS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid volume After an hour of Independent:
Konti na lang iniihi ko excess related health a. Assess face for a. Edema occurs in a. Absence of edema in
tapos minsan, wala to teachings, the edema. dependent tissues of the face.
talaga, as verbalized by compromised patient should body(e.g. hands, feet,
the patient. regulatory be able to face)
mechanism verbalize his b. Monitor weight b. To evaluate the b. Post weight= 80.5 kg.
Objective: (renal failure) understanding pre and post amount of fluid
Pre-weight=83 as evidenced regarding fluid dialysis. removed. c. Clear lung sounds
kg by restrictions and c. Auscultate lung c. To determine the through auscultation.
Dry weight= 80.5 Weight gain necessary sounds pre and presence of fluid
kg of 2.5 kg, measures to post dialysis. accumulation in the
Weight gain= 2.5 facial edema, prevent fluid Dependent: lungs
kg crackles on excess. d. Administer/restri d. To minimize the d. The patient verbalized,
both basal ct fluids as occurrence of fluid Sabi ni dra, limit
Hemodialysis
area of lungs, After 4 hours of ordered. excess. lamang daw talaga sa
treatment twice a
and oliguria. hemodialysis tubig.
week
treatment, the e. Dialysis e. To compensate for the e. The patient follows his
Facial edema patient should renal failure to regular schedule every
treatment twice a
Crackles on both be free from week. excrete excess fluid. Wednesday and
basal area of any signs of Collaborative: Thursday.
lungs fluid overload. f. Instruct patient f. Facilitates reduction f. The patient verbalized,
Oliguria regarding fluid of extracellular Konti lamang naman
(<400ml/day) restrictions as volume. ang iniinom ko gaya
appropriate. ng sabi ni Dra.
g. Instruct the g. To promote fluid g. The patient
patient to do mobilization in the verbalized,Tinatry ko
some exercise body and to prevent pa din maglakad-lakad
regularly as long fluid accumulation in tuwing umaga
as the body can. extracellular space. hanggat kaya ko.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

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 Sweet Glomerulus: A Case of Diabetic Nephropathy

Subjective: Altered After an hour of Independent:

Sobrang nahirapan ako sensory health teachings, a. Listen and a. To encourage a. The patient tells a
nung nawala ang perception the patient will respect clients verbalization of story how his
paningin ko, kelangan (visual) demonstrate expression of feelings. family helps him
ko lagi ng kasama kapag related to behaviors to dependency. in daily activities.
maglalakad ako, as microvascular prevent accidents b. Re-orient to time, b. Enhances patients b. The patient
verbalized by the destruction that can result place, and staff well-being and verbalized, May
patient. secondary to due to visual and events as sense of apat na oras pa ko
Diabetes impairment. necessary. importance. Jane para
Objective: Mellitus. matulog.
Bilateral c. Explain c. To promote c. The patient
blindness procedures/ participation. verbalized, Sige,
Dependency on expected sabihin mo kapag
significant sensations and tutusok ka na ah,
others outcomes. para hinga ako ng
Poor Collaborative: d. To conserve malalim.
concentration d. Provide rest energy. d. Seen patient
periods. resting and
sleeping for
almost 3-4 hours
during treatment.
e. To aid in e. Seen patients
e. Instruct the maintaining relative always on
relatives not to balance. his side.
leave the client. f. To prevent falls. f. Seen patient
f. Instruct patient to transferring with
ask for assistance assistance of his
during son.
ambulation/ g. Provide stable
transfer. gait. g. Seen patient
g. Use of cane. walking with the
use of cane.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

34
 Sweet Glomerulus: A Case of Diabetic Nephropathy

Subjective: High risk for After an hour of Independent:

Sobrang nag- impaired skin health teachings on a. Inspect skin a. Skin breakdown can a. No actual additional
iingat ako integrity related preventive surface in the occur quickly with skin breakdown
magkasugat, kasi to altered measures, the patient lower extremities. potential for seen.
sabi ng doctor, sensation will be able to infection and
matagal nga daw secondary to verbalize Dependent: necrosis.
gumaling, as disease process understanding to b. Keep blood b. High blood pressure b. Patient verbalized,
verbalized by the as evidenced prevent skin pressure under can cause Nagtetake ako ng
patient. by high glucose breakdown and will control (Anti- circulatory problems amlodipine isang
levels of 133.6 be able to hypertensive) in the feet. beses sa isang araw.
Objective: mg/dl and demonstrate c. Monitor and c. Keeping in range as c. Patient verbalized,
FBS= lesions noted preventive maintain glucose often as possible Nagtetake ako ng
133.6 on lower measures. levels at normal will dramatically Januvia isang beses
mg/dl extremities. range reduce the risk of sa isang araw.
Lesions (hypoglycemic serious
noted on agents). complications of
lower Collaborative: diabetes.
extremitie d. Limit drinking d. Drinking caffeine d. Patient verbalized,
s. beverages which beverages can Minsan na lamang
contains caffeine. constrict blood ako uminom ng
vessels and may kape.
contribute to
circulation
problems.
e. Instruct to wear e. To prevent any foot e. Seen patient wearing
protective socks. skin breakdown. socks.
f. Check feet daily f. Most problems for f. Patient verbalized,
and immediately diabetes begins with Sa tuwing
care for small cuts small sores on the magkakasugat ako,
or blister. skin like blisters. ginagamot ko kagad
para hindi na lumala
pa.

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